What's really wrong with cognitive behavioral therapy for psychosis?

Abstract

For persons with medication-refractory psychotic experiences such as auditory hallucinations, a psychological therapy referred to as cognitive behavioral therapy for psychosis (CBTp) has emerged as the standard recommended treatment in clinical practice guidelines (e.g., Kreyenbuhl et al., 2010; National Institute for Health and Clinical Excellence [NICE], 2014). However, the past few years have seen impassioned debate regarding the endorsement of CBTp as evidence-based practice, with some arguing that evidence in its favor has been “oversold” (McKenna and Kingdon, 2014). As a follow up to their earlier controversial review (Lynch et al., 2010), which claimed no evidence that CBTp was effective in “well-conducted” trials, a recent meta-analysis by Jauhar et al. (2014) drew the only slightly less pessimistic conclusion that CBTp’s therapeutic effect was only in the small range. Coinciding with the continuing recommendation of CBTp for routine provision in the 2014 NICE guidelines, this has led to debates published in several journals, and a flurry of further metaanalyses analysing different permutations of trial characteristics andmeasures. Thesemeta-analyses have formed the more optimistic conclusions that CBTp shows good effects for hallucinations (van der Gaag et al., 2014), for overall psychotic symptoms in people with persisting symptoms (Burns et al., 2014), and in direct contrasts with other interventions (Turner et al., 2014). As a battle fought with meta-analysis, debate has focused on which data should be included in effect size calculations: for example, whether trials with different intervention targets should be included, conducted during acute psychosis should bemixedwith persisting psychosis, andwhether both group and one-to-one format intervention should be included (Birchwood et al., 2014; Burns et al., 2014; Mueser and Glynn, 2014; Peters, 2014). There has also been criticism of an excessive focus on overall psychotic symptom severity at post-treatment as the primary outcome (e.g., on measures like the Positive and Negative Symptom Scales, PANSS), when there is stronger evidence for effects on specific symptom measures (Peters, 2014; van der Gaag et al., 2014), and at follow-up time points (Peters, 2014), and when, in any case, CBTp primarily targets the emotional impact of psychotic experiences rather than their presence or frequency (Birchwood et al., 2014).